title: Pathways to child and adolescent psychiatric clinics: a multilevel study of the significance of ethnicity and neighbourhood social characteristics on source of referral.
abstract: BACKGROUND
  In the Swedish society, as in many other societies, many children and adolescents with mental health problems do not receive the help they need. As the Swedish society becomes increasingly multicultural, and as ethnic and economic residential segregation become more pronounced, this study utilises ethnicity and neighbourhood context to examine referral pathways to child and adolescent psychiatric (CAP) clinics.
  
  
  METHODS
  The analysis examines four different sources of referrals: family referrals, social/legal agency referrals, school referrals and health/mental health referrals. The referrals of 2054 children aged 11-19 from the Stockholm Child-Psychiatric Database were studied using multilevel logistic regression analyses.
  
  
  RESULTS
  Results indicate that ethnicity played an important role in how children and adolescents were referred to CAP-clinics. Family referrals were more common among children and adolescents with a Swedish background than among those with an immigrant background. Referrals by social/legal agencies were more common among children and adolescents with African and Asian backgrounds. Children with Asian or South American backgrounds were more likely to have been referred by schools or by the health/mental health care sector. A significant neighbourhood effect was found in relation to family referrals. Children and adolescents from neighbourhoods with low levels of socioeconomic deprivation were more likely to be referred to CAP-clinics by their families in comparison to children from other neighbourhoods. Such differences were not found in relation in relation to the other sources of referral.
  
  
  CONCLUSIONS
  This article reports findings that can be an important first step toward increasing knowledge on reasons behind differential referral rates and uptake of psychiatric care in an ethnically diverse Swedish sample. These findings have implications for the design and evaluation of community mental health outreach programs and should be considered when developing measures and strategies intended to reach and help children with mental health problems. This might involve providing information about the availability and accessibility of health care for children and adolescents with mental health problems to families in certain neighbourhoods and with different ethnic backgrounds.
authors.affiliation: Faculty of Health and Society, Malmö University, SE-205 06 Malmö, Sweden. anna-karin.ivert@mah.se.
authors.forename: Anna-Karin
authors.initials: AK
authors.lastname: Ivert
authors.forename: Robert
authors.initials: R
authors.lastname: Svensson
authors.forename: Hans
authors.initials: H
authors.lastname: Adler
authors.forename: Sten
authors.initials: S
authors.lastname: Levander
authors.forename: Per-Anders
authors.initials: PA
authors.lastname: Rydelius
authors.forename: Marie
authors.initials: M
authors.lastname: Torstensson Levander